Transarterial chemoembolization vs. radiofrequency ablation for the treatment of single hepatocellular carcinoma 2 cm or smaller

Bridge Therapy before Liver Transplant for Advanced Hepatocellular Carcinoma

Hepatocellular carcinoma is the most common primary liver tumor. Orthotopic liver transplant is one of the best treatment options, but its waiting list has to be considered. Bridge therapies have been introduced in order to limit this issue. The aim of this study is to evaluate if bridge therapies in advanced hepatocellular carcinoma can improve overall survival and reduce de-listing. We selected 185 articles. The search was limited to English articles involving only adult patients. These were deduplicated and articles with incomplete text or irrelevant conclusions were excluded. Sorafenib is the standard of care for advanced hepatocellular carcinoma and increases overall survival without any significant drug toxicity. However, its survival benefit is limited. The combination of transarterial chemoembolization + sorafenib, instead, delays tumor progression, although its survival benefit is still uncertain. A few studies have shown that patients undergoing transarterial chemoembolization + radiation therapy have similar or even better outcomes than those undergoing transarterial chemoembolization or sorafenib alone for rates of histopathologic complete response (89% had no residual in the explant). Also, the combined therapy of transarterial chemoembolization + radiotherapy + sorafenib was compared to the association of transarterial chemoembolization + radiotherapy and was associated with a better survival rate (24 vs. 17 months). Moreover, immunotherapy revealed new encouraging perspectives. Combination therapies showed the most encouraging results and could become the gold standard as a bridge to transplant for patients with advanced hepatocellular carcinoma.

Proton Beam Therapy for Treating Patients with Hepatocellular Carcinoma with Major Portal Vein Tumor Invasion: A Single Center Retrospective Study

Hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) has a poor prognosis and is generally not indicated for surgery. Proton beam therapy (PBT) may offer an alternative treatment. In this study, long-term outcomes were examined in 116 patients (median age 66 years, 100 males) with HCC with advanced PVTT (Vp3 or Vp4) who received PBT from April 2008 to March 2018. Of these patients, 63 received PBT as definitive treatment and 53 as palliative treatment. The representative dose was 72.6 Gy (RBE) in 22 fractions. Eight patients died in follow-up, including 72 due to tumor progression. The 5-year overall survival (OS) rate was 18.0% (95% CI 9.8-26.2%) and the 5-year local control (LC) rate was 86.1% (74.9-97.3%). In multivariate analyses, performance status and treatment strategy were significantly associated with OS. The median follow-up period for survivors with definitive treatment was 33.5 (2-129) months, and the 5-year OS rate was 25.1% (12.9-37.3%) in these cases. The median survival time after definitive irradiation was >20 months. The 5-year OS rate was 9.1% (0-19.7%) for palliative irradiation. These results compare favorably with those of other therapies and suggest that PBT is a useful option for cases of HCC with advanced PVTT that cannot undergo surgery, with an expected survival benefit and good local control. Determining the optimal indication for this treatment is a future challenge.

Clinical outcomes of transarterial chemoembolization in Child-Turcotte Pugh class A patients with a single small (≤3 cm) hepatocellular carcinoma

BACKGROUND AND AIM

Transarterial chemoembolization (TACE) is one of the standard modalities used to treat unresectable hepatocellular carcinoma (HCC), but the effectiveness of TACE for treating patients with a solitary small (≤3 cm) HCC and well-preserved liver function has not been definitively established. This study aimed to determine the therapeutic impact of TACE in patients with these characteristics.

METHODS

This multicenter (four university hospitals) retrospective cohort study analyzed the medical records of 250 patients with a solitary small (≤3 cm) HCC and Child-Turcotte-Pugh (CTP) class A liver function diagnosed over 10 years. Posttreatment outcomes, including overall survival (OS), recurrence-free survival (RFS), and adverse events, were assessed following TACE therapy.

RESULTS

One hundred and thirty-eight of the 250 patients (55.2%) treated with TACE achieved complete remission (CR). Overall median OS was 77.7 months, and median OS was significantly longer in the CR group than in the non-CR group (89.1 vs. 58.8 months, P = 0.001). Median RFS was 19.1 months in the CR group. Subgroup analysis identified hypertension, an elevated serum albumin level, and achieving CR as significant positive predictors of OS, whereas diabetes, hepatitis c virus infection, and tumor size (>2 cm) were poor prognostic factors of OS.

CONCLUSIONS

The study demonstrates the effectiveness of TACE as a viable alternative for treating solitary small (≤3 cm) HCC in CTP class A patients.

Locoregional therapies for hepatocellular carcinoma: The current status and future perspectives

Hepatocellular carcinoma (HCC) is one of the most common cancers and a leading cause of cancer-related mortality. Locoregional therapies (LRTs) play a crucial role in HCC management and are selectively adopted in real-world practice across various stages. Choosing the best form of LRTs depends on technical aspects, patient clinical status and tumour characteristics. Previous studies have consistently highlighted the efficacy of combining LRTs with molecular targeted agents in HCC treatment. Recent studies propose that integrating LRTs with immune checkpoint inhibitors and molecular targeted agents could provide substantial therapeutic benefits, a notion underpinned by both basic and clinical evidence. This review summarised the current landscape of LRTs in HCC and discussed the anticipated outcomes of combinations with immunotherapy regimens.

Chemoembolization versus radiofrequency ablation for single small (≤ 3 cm) hepatocellular carcinoma: a propensity score matching analysis

OBJECTIVES

To compare the efficacy of transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) for patients with single small (≤ 3 cm) hepatocellular carcinoma (HCC) and preserved liver function (Child-Pugh class A).

MATERIALS AND METHODS

The clinical features of treatment-naïve patients who underwent TACE and RFA as first-line treatment were balanced through propensity score matching (PSM). The primary endpoint was overall survival (OS), and the secondary endpoints were local tumor recurrence (LTR) and recurrence-free survival (RFS).

RESULTS

The analysis included 440 patients who received TACE, and 430 patients who received RFA. After PSM adjustment (323 pairs), the 5- and 10-year OS rates were 81% and 61%, respectively, in patients who underwent RFA, and 77% and 51%, respectively, for patients who underwent TACE (p = 0.021). Subgroup analyses showed that OS, LTR, and RFS were homogeneously better in the RFA group.

CONCLUSION

RFA was associated with better survival outcomes than TACE in patients with single small HCC and preserved liver function.

CLINICAL RELEVANCE STATEMENT

This large-scale comparative study provides evidence that radiofrequency ablation has a better overall survival rate than chemoembolization for small (≤ 3 cm) hepatocellular carcinomas.

KEY POINTS

• The relative effectiveness of transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) for early HCC is unclear. • Overall survival rate was significantly higher in the RFA group. • The effects of RFA on overall survival, local tumor recurrence, and recurrence-free survival were homogeneously better in all subgroups.

Chemoembolization versus Radiotherapy for Single Hepatocellular Carcinomas of ≤3 cm Unsuitable for Image-Guided Tumor Ablation

Background/Aims

Local ablation therapy (LAT) is primarily recommended for solitary inoperable hepatocellular carcinomas (HCCs) of ≤3 cm in diameter. However, only two-thirds of uninodular small HCCs are suitable for LAT, and the second-best treatment option for managing these nodules is unclear. We aimed to compare the therapeutic outcomes of chemoembolization and radiotherapy in small HCCs unsuitable for LAT.

Methods

The study included 651 patients from a tertiary referral center who underwent planning sonography for LAT. These patients had 801 solitary HCCs of ≤3 cm in diameter and were treated with LAT, chemoembolization, or radiotherapy. Local tumor progression (LTP)-free survival and overall survival (OS) were measured according to the type of treatment of the index nodule.

Results

LAT, chemoembolization, and radiotherapy were used to treat 561, 185, and 55 nodules in 467, 148, and 36 patients, respectively. LTP-free survival was significantly shorter in patients treated with chemoembolization than for those treated with LAT (multivariate hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.61 to 3.47) but not for those treated with radiotherapy (HR, 0.83; 95% CI, 0.38 to 1.83). However, OS was not affected by treatment modality. Matching and weighting analyses confirmed that radiotherapy gave comparable results to chemoembolization in terms of OS despite better LTP-free survival (HR, 2.91; 95% CI, 1.13 to 7.47 and HR, 3.07; 95% CI, 1.11 to 8.48, respectively).

Conclusions

Our data suggest that chemoembolization and radiotherapy are equally effective options for single small HCCs found to be unsuitable for LAT after sonographic planning. Betterfit indications for each procedure should be established by specifically designed studies.

A retrospective pilot study of transarterial chemoembolisation using camrelizumab-eluting Callisphere beads for unresectable hepatocellular carcinoma

BACKGROUND

Our objective was to assess the efficacy and safety of initial hepatic arterial infusion of chemotherapy combined with transarterial chemoembolisation using camrelizumab-eluting Callisphere beads (camrelizumab-DEB-TACE) for treating unresectable hepatocellular carcinoma (HCC).

METHODS

Enrolment included patients with unresectable HCC who underwent camrelizumab-DEB-TACE treatment from September 2021 to February 2023. The assessment included the examination of tumour response, overall survival (OS), progression-free survival (PFS), and the monitoring of adverse events (AEs).

RESULTS

Twenty-one patients were included in the study. The objective response rates (ORR) and disease control rates (DCR) were 55.0% and 90.0% at 1 month and 57.9% and 78.9% at 3 months, respectively. The median PFS and OS were 7.4 and 15.5 months months, respectively. Among the 21 patients, 4 underwent more than 2 procedures of camrelizumab-DEB-TACE, with a mean of 1.9 ± 1.1 procedures (range: 1-4) per patient. No severe complications or treatment-related mortalities were observed. In addition, no patient developed severe AEs related to camrelizumab, such as reactive cutaneous capillary endothelial proliferation, immune-related pneumonia, or immune-related myocarditis. Nineteen patients experienced at least one type of AEs related to DEB-TACE, with abdominal pain (n = 16, 76.2%) being the most prevalent AE.

CONCLUSION

Camrelizumab-DEB-TACE demonstrated effectiveness and safety as a treatment for unresectable HCC, with no occurrence of severe camrelizumab-related AEs.

Drug-Eluting Bead Transarterial Chemoembolization Versus Radiofrequency Ablation as an Initial Treatment of Single Small (≤ 3 cm) Hepatocellular Carcinoma

BACKGROUND

In this study, we aimed to compare the long-term therapeutic outcomes of drug-eluting bead transarterial chemoembolization (DEB-TACE) with those of radiofrequency ablation (RFA) for the initial treatment of a single small (≤ 3 cm) hepatocellular carcinoma (HCC).

METHODS

From January 2010 to December 2021, 259 consecutive patients who underwent DEB-TACE (67 patients) or RFA (192 patients) as a first-line treatment for a single small HCC were enrolled in this retrospective study. The therapeutic outcomes, including cumulative intrahepatic local tumor progression (LTP), progression-free survival (PFS), and long-term overall survival (OS) rates, were compared between the two groups before and after propensity score (PS) matching. Multivariate Cox proportional hazard models were used to evaluate the prognostic factors and differences in OS and PFS between the two groups for all 92 patients after PS matching.

RESULTS

After PS matching, the 1-, 2-, 3-, and 5-year LTP rates were lower in the RFA group than those in the DEB-TACE group (P < 0.001), and the 1-, 2-, 3-, and 5-year PFS rates in the RFA group were higher than those in the DEB-TACE group (P = 0.007). However, the 1-, 2-, 3-, and 5-year OS rates were not significantly different between the RFA and DEB-TACE groups (P = 0.584). Moreover, the OS was not significantly different between the RFA and DEB-TACE groups in the univariate and multivariate analyses, with a hazard ratio (HR) of 0.81. The PFS was significantly higher in the RFA group than that in the DEB-TACE group in the univariate analyses, with a HR of 0.44 (P = 0.009). Multivariate Cox regression analysis showed that albumin (P = 0.019) was an independent prognostic factor for OS. Additionally, the major complication rates were not significantly different between the DEB-TACE and RFA groups (P = 1.000).

CONCLUSION

The LTP and PFS rates of RFA were superior to those of DEB-TACE in the initial treatment of single small HCC after PS matching. However, the OS rates were not significantly different between RFA and DEB-TACE. Therefore, DEB-TACE may be considered an efficient substitute for RFA in some patients with a single small HCC who are ineligible for RFA.

Loco-regional therapies competing with radiofrequency ablation in potential indications for hepatocellular carcinoma: a network meta-analysis

BACKGROUND/AIMS

There is no clear consensus on the relative ranking of interventional and radiation techniques with indications similar to those of radiofrequency ablation (RFA) for the treatment of early hepatocellular carcinoma (HCC). We used a network meta-analysis to compare the efficacy of non-surgical treatments for early HCC.

METHODS

We searched databases for randomized trials assessing the efficacy of loco-regional treatments for HCCs ≤5 cm with no extrahepatic spread or portal invasion. The primary outcome was the pooled hazard ratio (HR) for overall survival (OS), and secondary outcomes included overall and local progression-free survival (PFS). A frequentist network meta-analysis was performed, and the relative ranking of therapies was assessed with P-scores.

RESULTS

Nineteen studies comparing 11 different strategies in 2,793 patients were included. Chemoembolization plus RFA improved OS better than RFA alone (HR 0.52, 95% confidence interval [CI] 0.33-0.82; P-score=0.951). Cryoablation, microwave ablation, laser ablation, and proton beam therapy had similar effects on OS compared with RFA. For overall PFS, but not local PFS, only chemoembolization plus RFA performed significantly better than RFA (HR 0.61, 95% CI 0.42-0.88; P-score=0.964). Injection of percutaneous ethanol or acetic acid was significantly less effective than RFA for all measured outcomes, while no differences in progression outcomes were identified for other therapies included in the network.

CONCLUSION

Our results suggest that chemoembolization combined with RFA is the best option for local treatment of early HCC. Cases with potential contraindications for RFA may benefit from a tailored approach using thermal or radiation modalities.

The number of hepatocellular carcinoma foci as predictor of poor response to tumor-directed therapies in patients awaiting liver transplantation: a prospective cohort study

BACKGROUND AND AIMS

Tumor-directed therapies (TDTs) are a constitutive part of hepatocellular carcinoma (HCC) treatment in patients awaiting liver transplantation (LT). While most patients benefit from TDTs as a bridge to LT, some patients drop out from the waiting list due to tumor progression. The study aimed to determine the risk factors for poor treatment outcome following TDTs among patients with HCC awaiting LT.

METHODS

A total of 123 patients with HCC were evaluated with 92 patients meeting Milan Criteria enrolled in the prospective cohort study. Tumor response was evaluated using the modified Response Evaluation Criteria for Solid Tumors for HCC 1 month after the procedure. The risk factors for progressive disease (PD) and dropout were evaluated.

RESULTS

After TDT, 55 patients (59.8%) achieved complete or partial response (44.6% and 15.2% respectively), 17 patients (18.5%) had stable disease, and 20 patients (21.7%) were assessed as PD. Multivariate analysis revealed a significant and independent association between the number of HCC foci and PD ( P  = 0.03, OR = 2.68). There was no statistically significant association between treatment response and demographics, MELDNa score, pre-and post-treatment alpha-fetoprotein (AFP), cumulative tumor burden the largest tumor size, or TDT modality. PD was the major cause of dropout in our cohort. Pre-treatment AFP levels ≥200 ng/ml had a strong association with dropout after TDTs ( P  = 0.0005).

CONCLUSION

This study demonstrated the presence of multifocal HCC is the sole prognostic factor for PD following TDTs in HCC patients awaiting LT. We recommend prioritizing patients with multifocal HCC within Milan criteria by exception points for LT to improve the dropout rate.

Role of Transarterial Chemoembolization in the Treatment of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. According to the Barcelona Clinic Liver Cancer (BCLC) staging system, transarterial chemoembolization (TACE) is the first-line recommendation for intermediate-stage HCC. In real-world clinical practice, TACE also plays an important role in early- and advanced-stage HCC. This review article by the experts from Chinese Liver Cancer Clinical Study Alliance (CHANCE) summarizes the available clinical evidence pertaining to the current application of TACE in patients with early-, intermediate-, and advanced-stage HCC. In addition, combination of TACE with other treatment modalities, especially immunotherapy, is reviewed.

Addition of Camrelizumab to Transarterial Chemoembolization in Hepatocellular Carcinoma With Untreatable Progression

Purpose: The present retrospective study aimed to evaluate the efficacy and safety of camrelizumab addition to transarterial chemoembolization (TACE) in the treatment of hepatocellular carcinoma (HCC) with TACE-related untreatable progression (UP). Methods: Patients with HCC who received addition of camrelizumab due to UP after initial TACE treatment were enrolled at our institution between May 2019 and January 2021. Patients were assessed for tumor response, progression-free survival (PFS), and adverse events (AEs). Risk factors for PFS were evaluated with logistic regression analysis. Results: A total of 41 patients were included. The objective response rates (ORR) and disease control rates (DCR) were 24.4% and 61.0% at 2 to 3 months, and 12.2% and 58.5% at 6 months, respectively. The median PFS of the patients were 6 months (95% confidence interval [CI]: 3.8 months, 8.2 months). Of the 41 patients, 23 received camrelizumab combined with TACE (hereafter, camrelizumab-TACE) on whom 52 combined TACE procedures were performed, with a median of 2 procedures (range: 1-6) per patient. The remaining 18 patients received camrelizumab alone due to TACE contraindications. Multivariable analysis indicated that camrelizumab-TACE was an independent prognostic factor for PFS. Subgroup analysis showed a median PFS of 8 months in the camrelizumab-TACE group and 3 months in the camrelizumab monotherapy group (P < .001). No treatment-related mortalities occurred. Seventeen patients (41.5%) developed at least 1 type of AE after treatment with camrelizumab, with reactive cutaneous capillary endothelial proliferation (RCCEP) (n = 14, 34.1%) being the most common AE. Conclusion: Addition of camrelizumab to TACE offered an effective and safe treatment for HCC with UP.

Comparable Outcomes in Early Hepatocellular Carcinomas Treated with Trans-Arterial Chemoembolization and Radiofrequency Ablation

The guidelines recommend radiofrequency ablation (RFA) for early hepatocellular carcinomas that are less than 3 cm and trans-arterial chemoembolization (TACE) for intermediate-stage tumors. Real-world patient and tumor factors commonly limit strict adherence to the guidelines. We aimed to compare the clinical outcomes for TACE and RFA in early HCC. All consecutive patients from 2010 to 2014 that were treated with locoregional therapy at our institution were enrolled. The decision for TACE or RFA was based on tumor location, stage and technical accessibility for ablation. A subgroup analysis was performed for patients with tumors less than 3 cm. A total of 168 patients underwent TACE while 56 patients underwent RFA. Patients treated with TACE and RFA had 1- and 5-year survival rates of 84.7% and 39.8% versus 91.5% and 51.5%, respectively (p = 0.28). In tumors less than 3 cm, there was no significant difference in overall survival (p = 0.69), time to progression (p = 0.55), or number of treatment sessions required (p = 0.12). Radiofrequency ablation had a significantly higher chance of a complete response (p = 0.004). In conclusion, TACE may be selectively considered for early-stage hepatocellular carcinoma in patients unsuitable for other modalities.

Impact of ultrasonographic blind spots for early-stage hepatocellular carcinoma during surveillance

Background

Abdominal ultrasonography (US) is the backbone of hepatocellular carcinoma (HCC) surveillance. Although previous studies have evaluated clinical factors related to surveillance failure, none have focused specifically on US blind spots.

Methods

This study included 1,289 patients who underwent 6 months intervals surveillance using US and serum alpha-fetoprotein (AFP) and were eventually diagnosed with single-nodular HCC. Patients were divided into US-detected group (n = 1,062) and US-missed group (HCC detected only by AFP ≥ 20ng/mL; n = 227). Blind spots consisted of four locations: hepatic dome, caudate lobe or around the inferior vena cava, <1 cm beneath the ribs, and the surface of the left lateral segment. Both groups were compared by HCC location, proportional distribution, treatment method, and overall survival.

Results

A higher proportion of HCCs were located within blind spots in the US-missed group than in the US-detected group (64.3% vs. 44.6%, P < 0.001). HCC ≥ 2 cm detected in blind spots was higher than in non-blind areas (60.3% vs. 47.1%, P = 0.001). Blind spot HCCs were more treated with surgery, whereas those located in a non-blind area were more treated with local ablation. Patients with an HCC located within a blind spot in the US-detected group had better overall survival than the same in the US-missed group (P = 0.008).

Conclusions

Using the current surveillance test, blind spots affected the initially detected HCC tumor size, applicability of the treatment modality, and overall survival. Physicians should pay attention to US blind spots when performing US-based HCC surveillance.

Role of 18F-FDG PET/CT in assessment of HCC patients after therapeutic interventions compared to DW MRI

Background

Hepatocellular carcinoma (HCC) is one of the most common causes of cancer-related deaths worldwide in both men and women. Early-stage HCCs are treated either by curative surgical resection and/or by locoregional interventions, such as radiofrequency ablation or trans-arterial chemoembolization. Functional imaging as diffusion-weighted magnetic resonance imaging (DW MRI) and metabolic imaging with 18F-positron emission tomography/computed tomography (18F-FDG PET/CT) has been used for assessment of treatment response. This retrospective study was conducted on 29 patients known to have HCC with locoregional therapeutic interventions and referred for radiological follow-up searching for residual/recurrence neoplasia or metastatic deposits. The study aimed to assess the benefits of using the metabolic parameters of 18F-FDG PET/CT in the follow-up of HCC patients after therapeutic interventions in comparison with DW MRI.

Results

Regarding qualitative assessment of residual active viable HCC by PET/CT and DW MRI, the sensitivity, specificity, PPV, NPP and accuracy were 77.3%, 91.7%, 94.4%, 68.8%, 82.4% and 95.5%, 75%, 87.5%, 90%, 88.2%, respectively. The optimal cutoff point of the SUVmax to differentiate viable from non-viable HCC was 3.4 (AUC = 0.898), with sensitivity, specificity, PPV and NPV of 77.27%, 100.0%, 100.0% and 66.7%, respectively. The optimal ADC cutoff value for discrimination between viable and non-viable HCC was 1247 mm2/s (AUC = 0.976) with sensitivity, specificity, PPV and NPV of 90.48%, 100.0%, 100.0% and 83.3%, respectively. New hepatic lesions were found in 38.2% of patients by DW MRI, while detected only in 26.5% of patients by PET/CT. The PET/CT revealed extrahepatic metastasis in 44.1% of patients, while detected only in 8.8% of patients by DW MRI.

Conclusions

DWI was more sensitive than PET/CT for detecting tumor residual and hepatic recurrence compared to PET/CT which was much better in detecting distant metastases.

Resection or ablation versus transarterial therapy for Child-Pugh A patients with a single small hepatocellular carcinoma

Data from a direct comparison of the long-term survival outcomes of surgical resection (SR) or radiofrequency ablation (RFA) versus transarterial therapy in Child-Turcotte-Pugh (CTP)-class A patients with a single small T1/T2 stage hepatocellular carcinoma (HCC) (≤3 cm) are still lacking. This study retrospectively compared the therapeutic outcomes of these treatment types for CTP-A patients with a single small HCC.Using a nationwide Korean registry, we identified 2314 CTP-A patients with SR (n = 722), RFA (n = 731), or transarterial therapy (n = 861) for a single (≤3 cm) T1/T2 stage HCC from 2008 to 2014. The posttreatment overall survival (OS) of transarterial therapy with either SR or RFA were compared using the Inverse Probability of treatment Weighting (IPW). The median follow-up period was 50 months (range 1-107 months).After IPW, the cumulative OS rates after SR or RFA were significantly higher than those after transarterial therapy in all subjects (all P values < .05). The OS rates after SR or RFA were better than those after transarterial therapy in patients with the hepatitis B or C virus (all P values < .05), and in patients aged <65 years (all P values < .05). The cumulative OSs between RFA and transarterial therapy were statistically comparable in patients with a 2 to 3 cm HCC and aged ≥65 years, respectively. For all subjects, the weighted Cox proportional hazards model using IPW provided the adjusted hazard ratios (95% confidence interval) for the OS after SR versus transarterial therapy and after RFA versus transarterial therapy of 0.42 (0.30-0.60) (P < .001) and 0.78 (0.61-0.99) (P = .044), respectively.In CTP-A patients with a single (≤3 cm) T1/T2 HCC, SR or RFA provides a better OS than transarterial therapy, regardless of the HCC etiology (hepatitis B virus or hepatitis C virus), especially in patients with HCC of <2 cm and aged <65 years.

The effect of nucleos(t)ide analogues on clinical outcomes of patients treated with transarterial chemoembolization and radiofrequency ablation for hepatitis B virus-related hepatocellular carcinoma

Background/Aims

Because hepatitis B virus (HBV) replication has been known to play an important role in cancer recurrence after curative treatment of HBV-related hepatocellular carcinoma (HCC), we examined whether treatment based on nucleos(t)ide analogues (NAs) might decrease the recurrence rate and improve patient survival.

Methods

The retrospective cohort study enrolled 73 patients with chronic hepatitis B who were treated with transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) with curative intent for HCC. Among those, 30 and 43 patients were treated with tenofovir disoproxil fumarate (TDF) and entecavir (ETV), respectively.

Results

Of the 73 patients, 51 experienced HCC recurrence, and 14 patients were dead during a follow-up of 73±34 months. Multivariate analyses showed that tumor size (hazard ratio [HR], 1.590; 95% confidence-interval [CI], 1.106-2.285; P=0.012) and Child-Pugh class B (vs. class A/non cirrhosis; HR, 5.794; 95% CI, 2.311-14.523; P=0.001) was significantly associated with HCC recurrence, and Child-Pugh class B (HR, 7.357; 95% CI, 2.100-25.777; P=0.002) was an independent unfavorable prognostic factor for survival. During NAs therapy, TDF was superior to ETV for complete viral response at 1 year after the date of combination of TACE and RFA (P=0.016). However, the risks of HCC recurrence and survival were not significantly different between those treated with TDF versus ETV.

Conclusions

TDF was superior to ETV for achieving complete viral response. However, the recurrence and mortality after TACE and RFA for HBV-related HCC were not significantly different between patients treated with TDF versus ETV.

Locoregional Combined With Systemic Therapies for Advanced Hepatocellular Carcinoma: An Inevitable Trend of Rapid Development

Despite the application of antiviral drugs and improved surveillance tools, the number of patients diagnosed with hepatocellular carcinoma (HCC) at an advanced stage and with a dismal prognosis is still on the rise. Systemic treatment with multiple multitargeted tyrosine kinase inhibitors (TKIs), such as sorafenib, has been a widely utilized approach for a decade. In addition, the use of a combination of TKIs with other types of compounds, including immune checkpoint inhibitors (ICIs) and antiangiogenic inhibitors, has shown efficacy in treating advanced HCC. However, the presence of intolerable adverse events, low disease response and control rates, and relative short overall survival of such combinatory therapies makes novel or optimized therapies for advance HCC urgently needed. Locoregional therapy (transarterial chemoembolization, and thermal ablation) can destroy primary tumors and decrease tumor burden and is widely used for HCC management. This type of treatment modality can result in local hypoxia and increased vascular permeability, inducing immunogenic effects by releasing tumor antigens from dying cancer cells and producing damage-associated molecular patterns that facilitate antiangiogenic therapy and antitumor immunity. The combination of systemic and locoregional therapies may further produce synergistic effects without overlapping toxicity that can improve prognoses for advanced HCC. In preliminary studies, several combinations of therapeutic modes exhibited promising levels of safety, feasibility, and antitumor effects in a clinical setting and have, thus, garnered much attention. This review aims to provide a comprehensive, up-to-date overview of the underlying mechanisms of combined systemic and locoregional therapies in the treatment of advanced HCC, commenting on both their current status and future direction.

A Single-Center Retrospective Analysis of Periprocedural Variables Affecting Local Tumor Progression after Radiofrequency Ablation of Colorectal Cancer Liver Metastases

Background Local tumor progression (LTP) is associated with poorer survival in patients undergoing radiofrequency ablation (RFA) for colorectal liver metastasis (CLM). An algorithmic strategy to predict LTP may help in selection of patients who would benefit most from RFA for CLM. Purpose To estimate local tumor progression-free survival (LTPFS) following RFA of CLM and develop an algorithmic strategy based on clinical variables. Materials and Methods In this retrospective study, between March 2000 and December 2014, patients who underwent percutaneous RFA for CLM were randomly split into development (60%) and internal validation (40%) data sets. Kaplan-Meier method was used to estimate LTPFS and overall survival (OS) rates. Independent factors affecting LTPFS in the development data set were investigated by using multivariable Cox proportional hazard regression analysis. Risk scores were assigned to the risk factors and applied to the validation data set. Results A total of 365 patients (mean age, 60 years ± 11 [standard deviation]; 259 men) with 512 CLMs were evaluated. LTPFS and OS rates were 85% and 92% at 1 year, 73% and 41% at 5 years, 72% and 30% at 10 years, and 72% and 28% at 15 years, respectively. Independent risk factors for LTP included tumor size of 2 cm or greater (hazard ratio [HR], 3.8; 95% CI: 2.3, 6.2; P < .001), subcapsular tumor location (HR, 1.9; 95% CI: 1.1, 3.1; P = .02), and minimal ablative margin of 5 mm or less (HR, 11.7; 95% CI: 4.7, 29.2; P < .001). A prediction model that used the risk factors had areas under the curve of 0.89, 0.92, and 0.90 at 1, 5, and 10 years, respectively, and it showed significantly better areas under the curve when compared with the model using the minimal ablative margin of 5 mm or less alone. Conclusion Radiofrequency ablation provided long-term control of colorectal liver metastases. Although minimal ablative margin of 5 mm or less was the most dominant factor, the multifactorial approach including tumor size and subcapsular location better predicted local tumor progression-free survival. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Soulen and Sofocleous in this issue.

Recent Updates of Transarterial Chemoembolilzation in Hepatocellular Carcinoma

Transarterial chemoembolization (TACE) is a standard treatment for intermediate-stage hepatocellular carcinoma (HCC). In this review, we summarize recent updates on the use of TACE for HCC. TACE can be performed using two techniques; conventional TACE (cTACE) and drug-eluting beads using TACE (DEB-TACE). The anti-tumor effect of the two has been reported to be similar; however, DEB-TACE carries a higher risk of hepatic artery and biliary injuries and a relatively lower risk of post-procedural pain than cTACE. TACE can be used for early stage HCC if other curative treatments are not feasible or as a neoadjuvant treatment before liver transplantation. TACE can also be considered for selected patients with limited portal vein thrombosis and preserved liver function. When deciding to repeat TACE, the ART (Assessment for Retreatment with TACE) score and ABCR (AFP, BCLC, Child-Pugh, and Response) score can guide the decision process, and TACE refractoriness needs to be considered. Studies on the combination therapy of TACE with other treatment modalities, such as local ablation, radiation therapy, or systemic therapy, have been actively conducted and are still ongoing. Recently, new prognostic models, including analysis of the neutrophil-lymphocyte ratio, radiomics, and deep learning, have been developed to help predict survival after TACE.

Identification of diagnostic and prognostic biomarkers, and candidate targeted agents for hepatitis B virus-associated early stage hepatocellular carcinoma based on RNA-sequencing data

Primary liver cancer is a rapidly progressing neoplasm with high morbidity and mortality rates. The present study aimed to identify potential diagnostic and prognostic biomarkers, and candidate targeted agents for hepatitis B virus (HBV)-associated early stage hepatocellular carcinoma (HCC). The gene expression profiles were extracted from the Gene Expression Omnibus database. Differentially expressed genes (DEGs), hub genes and the enrichment of signaling pathways were filtered out via a high-throughput sequencing method. The association between hub genes and the effects of the abnormal expression of hub genes on the rate of genetic variation, overall survival (OS), relapse-free survival (RFS), progression-free survival (PFS) and disease-free survival (DSS) of patients with HCC, as well as pathological stage and grade, were analyzed using different databases. A total of 1,582 DEGs were identified. Gene Ontology analysis revealed that the DEGs were mainly involved in the ‘oxidation-reduction process’, ‘steroid metabolic process’, ‘metabolic process’ and ‘fatty acid beta-oxidation’. Enrichment analysis of Kyoto Encyclopedia of Genes and Genomes pathways revealed that the DEGs were mainly associated with ‘metabolic pathways’, ‘PPAR signaling pathway’, ‘fatty acid degradation’ and the ‘cell cycle’. A total of 8 hub genes were extracted. Additionally, the abnormal expression levels of hub genes were closely associated with the OS, RFS, PFS and DSS of patients, the pathological stage and the grade. Furthermore, abnormal expression levels of the 8 hub genes were found in >30% of all samples. Several small molecular compounds that may reverse the altered DEGs were identified based on Connectivity Map analysis, including phenoxybenzamine, GW-8510, resveratrol, 0175029-0000 and daunorubicin. In conclusion, the dysfunction of fat metabolic pathways, the cell cycle, oxidation-reduction processes and viral carcinogenesis may serve critical roles in the occurrence of HBV-associated early stage HCC. The identified 8 hub genes may act as robust biomarkers for diagnosis and prognosis. Some small molecular compounds may be promising targeted agents against HBV-associated early stage HCC.

Prognosis of Early-Stage Hepatocellular Carcinoma: Comparison between Trans-Arterial Chemoembolization and Radiofrequency Ablation

Radiofrequency ablation (RFA) is a curative treatment for early-stage hepatocellular carcinoma (HCC) ineligible for surgery or liver transplantation. However, trans-arterial chemoembolization (TACE) might be an alternative when RFA is contraindicated due to structural problems. Here, we aimed to compare their long-term outcomes. Treatment-naive HCC patients fulfilling the Milan criteria who underwent RFA (n = 136) or TACE (n = 268) were enrolled. Complete response (CR) and 5-year recurrence-free survival (RFS) rates were higher in the RFA group than in the TACE group (94.1% vs. 71.6% and 35.8% vs. 17.0%, respectively; both p < 0.001), whereas 5-year overall survival (OS) rates were not significantly different (65.5% vs. 72.3%, respectively; p = 0.100). Multivariate analysis showed that RFA was associated with better RFS (adjusted hazard ratio [aHR] 0.628; p = 0.001) than TACE, but not with better OS (aHR 1.325; p = 0.151). The most common 1st-line treatment after recurrence were TACE (n = 53), followed by RFA (n = 21) among the RFA group and TACE (n = 150), followed by RFA (n = 44) among the TACE group. After propensity-score matching, similar results were reproduced. Hence, TACE could be an effective alternative to RFA in terms of OS rates. However, TACE should be confined only to RFA-difficult cases, given its lower CR and RFS rates and multi-disciplinary approaches are desirable in decision-making.

Treatment of solitary hepatocellular carcinoma up to 2 cm: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

In recent years, there has been considerable uncertainty about the optimal treatment option for very early hepatocellular carcinoma (HCC) with tumor size less than 2 cm. Therefore, we performed a systematic review and meta-analysis to evaluate the outcomes of the different treatments.

METHODS

This study was designed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA). PubMed, EMBASE, and Cochrane library were searched for calculating the survival rates, and the "time to event" method was used to compare the outcomes of liver resection (LR) and radiofrequency ablation (RFA). All studies focusing on the treatment of solitary HCC up to 2 cm by different techniques were included in our analysis. The Hazard ratios (HR) and 95% confidence intervals (CI) derived from multivariate and univariate analysis were utilized to assess the treatment risks.

RESULTS

We included 32 studies in our systematic review. The median 5-year overall survival (OS) and recurrence-free survival rate (RFS) for LR were 73% and 47%, respectively, and those for RFA were 73% and 43%, respectively. RFA was found to be associated with increased risk of mortality and recurrence compared to LR (HR = 1.61, 95% CI: 1.35-1.92, P < .0001 for OS and HR = 1.75, 95% CI: 1.56-1.96, P < .0001 for RFS).

CONCLUSION

Our meta-analysis demonstrated that LR is superior to RFA in the treatment of solitary HCC up to 2 cm, with reduction in mortality and recurrence risk and improved long-term outcome.

Comparison of albumin-bilirubin grade versus Child-Pugh score in predicting the outcome of transarterial chemoembolization for hepatocellular carcinoma using time-dependent ROC

Background

The Child-Pugh score has been used extensively to assess hepatic function and predict post-treatment outcomes in patients with hepatocellular carcinoma (HCC). Recently, the albumin-bilirubin (ALBI) grade has been put forward as an objective method of evaluating liver function and predicting overall survival (OS) in HCC patients. Transarterial chemoembolization (TACE) is considered to be effective in prolonging OS among intermediate-stage HCC patients. This study aimed to explore and compare the performance of ALBI grade and Child-Pugh score in predicting outcomes for HCC patients who underwent TACE.

Methods

There were a total of 221 consecutive HCC patients enrolled in this study, all of whom received TACE and were enrolled retrospectively. The Kaplan-Meier method and time-dependent receiver operating curves (ROC) were used to estimate the discriminatory ability and survival prediction accuracy of ALBI grade and Child-Pugh score in predicting postoperative OS. Univariate and multivariate Cox regression analyses were performed to evaluate the prognostic factors for OS.

Results

Of the patients enrolled in the study, 106 (48.0%) were ALBI grade 1 and 115 (52.0%) were ALBI grade 2. Overall survival differed significantly between patients with ALBI-1 and ALBI-2 [hazard ratio (HR), 3.032; 95% CI, 2.019-4.555, P<0.001]. With regard to Child-Pugh scores, 160 (72.4%) patients had a score of A5 and 61 (27.6%) had a score of A6. There was also a difference in overall survival between patients with Child-Pugh-A5 and Child-Pugh-A6 (HR, 1.548; 95% CI, 1.066-2.247, P=0.022). In multivariate analyses, both ALBI grade and Child-Pugh score could significantly stratify the patients with different OS (HR, 2.994 and 1.545, P<0.001 and P=0.026 for ALBI grade and Child-Pugh score, respectively). Furthermore, time-dependent ROC analysis and its subgroup analyses demonstrated that the ALBI grade had a better discriminatory ability than Child-Pugh score in predicting survival.

Conclusions

In stratifying prognosis for HCC patients who had received TACE therapy, the ALBI grade provided better prognostic performance and discrimination of liver function than Child-Pugh score. These results suggest that ALBI grade could provide an alternative liver function grading system for stratification of patients with HCC.

Embolotherapeutic Strategies for Hepatocellular Carcinoma: 2020 Update

Hepatocellular carcinoma (HCC) represents a significant contributor to cancer-related morbidity and mortality with increasing incidence in both developing and developed countries. Embolotherapy as a locoregional therapeutic strategy consists of trans-arterial or “bland” embolization (TAE), trans-arterial chemoembolization (TACE), and selective internal radiotherapy (SIRT). Trans-catheter arterial therapies can be applied along all stages of HCC, either as an alternative or neoadjuvant to surgical resection/transplantation in very early and early stage HCC or as a palliative option for local disease control in unresectable and advanced stage HCC. In advanced stage HCC, SIRT did not demonstrate superiority in comparison to systemic treatment options in several recent large prospective trials, though for carefully selected patients, may confer improved tolerability with similar disease control rates. The latest embolotherapeutic techniques and literature as they pertain to the management of HCC, as well as future directions, are reviewed in this article.

Comparison of Microwave Ablation and Transarterial Chemoembolization for Single-Nodule Hepatocellular Carcinoma Smaller Than 5cm: A Propensity Score Matching Analysis

Purpose

To compare overall survival (OS) and progression-free survival (PFS) between microwave ablation (MWA) and transarterial chemoembolization (TACE) for solitary hepatocellular carcinoma (HCC) smaller than 5 cm.

Methods

Patients with solitary HCC smaller than 5cm who initially underwent MWA or TACE were identified in Chinese PLA General Hospital from June 2010 to October 2015. Propensity score matching (PSM) was performed with a 1:1 matching protocol. OS and PFS were compared by using the log-rank test. After matching, subgroup analysis based on tumor size (≤3cm/3.1–5cm) was also conducted. Prognostic factors for OS and PFS were assessed with Cox proportional hazard regression model.

Results

A total of 202 patients (MWA, n=120; TACE, n=82) were identified. After matching, 116 patients were included (58 patients for each treatment group). MWA provided significantly better OS and PFS than TACE for both the entire cohort (OS, P<0.001; PFS, P<0.001) and the matched cohort (OS, P=0.015; PFS, P<0.001). Subgroup analysis showed that among patients with tumor of 3cm or less, the MWA group had significantly better OS (P=0.027) and PFS (P=0.008) than the TACE group. Multivariate Cox regression analysis showed TACE was associated with worse OS (hazard ratio, 2.385; 95% CI: 1.427, 3.985; P=0.001) and PFS (hazard ratio, 2.567; 95% CI: 1.820, 3.622; P<0.001).

Conclusion

MWA outperformed TACE for solitary HCC smaller than 5cm in OS and PFS. For single tumors less than 5cm, especially those smaller ones (≤3cm), priority should be given to MWA when making treatment options between MWA and TACE.

Surgical resection versus radiofrequency ablation very early-stage HCC (≤2 cm Single HCC): A propensity score analysis

BACKGROUND & AIM

Hepatocellular carcinoma (HCC) is increasingly being detected at a very early-stage due to the wide implementation of the surveillance of at-risk patient populations combined with improved imaging technologies. Whether patients with HCC at a very early stage can be offered local ablation as a first-line treatment option still remains controversial. We retrospectively compared the effectiveness of surgical resection (SR) and radiofrequency ablation (RFA) for Barcelona Clinic Liver Cancer (BCLC) very early-stage HCC in patients with long-term follow-up.

METHODS

Propensity score analysis using inverse probability weighting (IPW) from a large-volume liver centre. We included adult patients who between 2000 and 2013 received a diagnosis of very early-stage HCC (BCLC stage 0; a single tumour ≤2 cm, Child-Pugh A class, eastern cooperative oncology group [ECOG] 0) and who were treated with SR or RFA as the first-line treatment.

RESULTS

We identified 1208 patients, 631 in the SR group and 577 in the RFA group. The median follow-up time was 86.2 months. After propensity score analysis using IPW, the 15-year overall survival rates were 60.4% and 51.6% in the SR and RFA group respectively. RFA group showed poorer overall survival than SR group (adjusted hazard ratio, 1.29; P = .0378). The 15-year recurrence-free survival rates were 37% and 23.6% in the SR and RFA group respectively (P < .001).

CONCLUSION

For patients with very early-stage HCC, the SR group was associated with better overall and recurrence-free patient survival compared to the RFA group. Therefore, SR should be considered as the first-line treatment for these patients.

Clinical outcomes of patients with a single hepatocellular carcinoma less than 5 cm treated with transarterial chemoembolization

BACKGROUND/AIMS

Transarterial chemoembolization (TACE) is performed for single hepatocellular carcinoma (HCC) that are not eligible for surgery or ablation therapy. We investigated the clinical outcomes of patients with a single HCC ≤ 5 cm treated with TACE.

METHODS

This study analyzed 175 consecutive patients who underwent TACE as an initial treatment for single HCC ≤ 5 cm. Predictive factors for complete response (CR), recurrence after CR, and overall survival (OS) were evaluated.

RESULTS

Total 119 patients (68%) achieved CR after TACE. Tumor size < 3 cm and hepatitis B virus infection were significant predictors of CR (p < 0.05). Recurrent HCC was detected in 73 patients (61.3%) after CR. Age > 65 years and absence of liver cirrhosis were predictive factors for non-recurrence after CR (p < 0.05). The OS for all patients was 80.7 ± 5.6 months, and the 1-, 3-, and 5-year OS rates were 88.1%, 64.8%, and 49.9%, respectively. In multivariate analysis for OS, CR (hazard ratio [HR], 0.467; 95% confidence interval [CI], 0.292 to 0.747) and Child class A (HR, 0.390; 95% CI, 0.243 to 0.626) were significant factors. The OS for the CR and Child class A group were 92 and 93.6 months, respectively, and that of the non-CR and Child B, C group were 53.3 and 50.7 months, respectively (p < 0.001).

CONCLUSION

TACE can be a valid treatment in patients with a single HCC ≤ 5 cm not suitable for curative treatment, especially in patients with Child class A and CR after TACE.

Improved clinical outcome using transarterial chemoembolization combined with radiofrequency ablation for patients in Barcelona clinic liver cancer stage A or B hepatocellular carcinoma regardless of tumor size: results of a single-center retrospective case control study

Background

To determine the safety and efficacy of transarterial chemoembolization (TACE) combined with radiofrequency ablation (hereafter, TACE-RFA) in treating Barcelona Clinic Liver Cancer (BCLC) Stage A or B (hereafter, BCLC A/B) hepatocellular carcinoma (HCC) patients, and to explore the range of tumor sizes suitable for combination therapy.

Methods

This retrospective study assessed the consecutive medical records of HCC patients with BCLC A/B who received TACE-RFA or TACE from September 2009 to September 2018. Progression-free survival (PFS), overall survival (OS), therapeutic response, and complications were compared between the two groups.

Results

Among 2447 patients who received TACE-RFA or TACE, 399 eligible patients were enrolled in our study, including 128 patients in the TACE-RFA group and 271 patients in the TACE group. Compared with the TACE group, the PFS and OS rates of 1,3,5,8 years in the TACE-RFA group were significantly better, with higher objective tumor regression rate and better disease control rate. RFA treatment did not increase the risk of death in patients with HCC, and both liver subcapsular hematoma and bile duct injury were improved by symptomatic treatment. Serum α-fetoprotein level and treatment method were important independent prognostic factors for OS, whereas albumin, hepatitis B and treatment method were important independent prognostic factors for PFS. Subgroup analysis showed that patients in the TACE-RFA group always showed better OS and PFS.

Conclusions

TACE-RFA had an advantage over TACE alone in prolonging PFS and improving OS in HCC patients with BCLC A/B, and can benefit patients regardless of tumor size.

Combination therapy of transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) for small hepatocellular carcinoma: comparison with TACE or RFA monotherapy

PURPOSE

To compare the safety and efficacy of combined transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) for small hepatocellular carcinoma (HCC) with those of TACE or RFA monotherapy.

METHODS

This study included 34 combined TACE and RFA (TACE-RFA), 87 TACE, and 136 ultrasound-guided RFA, which were performed to treat HCC (≤ 3 cm, 3 or fewer) between March and August 2009. The safety (Child-Pugh score indicating hepatic functional reserve, patient discomfort requiring medication, duration of hospitalization, and complications) and efficacy (1-month, 6-month, and 1-year tumor responses) profiles of each treatment were evaluated and compared.

RESULTS

TACE-RFA group showed longer hospital stay and more frequent patient discomfort requiring medication than TACE or RFA group (P < 0.001). The frequency of overall complications after TACE-RFA was higher than TACE (P = 0.006) or RFA (P = 0.009). There were no statistical differences in major complication rates between the three groups (P = 0.094). Child-Pugh score at 1-month follow-up showed no significant difference between the three groups (P = 0.162). 1-month, 6-month, and 1-year tumor responses of TACE-RFA were similar to those of RFA and better than those of TACE.

CONCLUSIONS

TACE-RFA appears to result in more frequent patient discomfort requiring medication, longer hospital stay, and more frequent complications than TACE or RFA monotherapy. Tumor response of TACE-RFA seems to be similar to that of RFA and better than TACE monotherapy. Thus, TACE-RFA for treating small HCC may be required for the selected patients, especially patients with small HCC ineligible for RFA monotherapy.

Treatment choice for early-stage hepatocellular carcinoma in real-world practice: impact of treatment stage migration to transarterial chemoembolization and treatment response on survival

OBJECTIVE

The objectives of our study were firstly to characterize the treatment stage migration phenomenon in early (Barcelona Clinic Liver Cancer [BCLC]-0/A) stage hepatocellular carcinoma (HCC) by comparing the efficacy of curative therapies with trans-arterial chemoembolization [TACE] and secondly, determining baseline and on-treatment predictors of survival.

METHODS

All patients within BCLC-0/A stage from six tertiary hospitals who received curative therapy with either resection, transplantation, or ablation or TACE as first-line treatment were included in the analyses. The primary endpoint was overall survival; secondary end-points were transplant-free survival and recurrence-free survival.

RESULTS

Between January 2000 and December 2013, we identified 253 BCLC-0/A HCC patients of whom 148 (58.5%) received curative therapy and 105 (41.5%) migrated to TACE. Patients undergoing TACE had lower median survival (2.7 vs. 6.7 years; p < .0001), transplant-free survival (2.6 vs. 4.8 years; p < .0001) and recurrence-free survival (1.3 vs. 2.7 years; p < .001). On multivariate analysis treatment allocation to TACE was an independent prognostic predictor for both lower overall survival (HR 1.70, p = .04) and for HCC recurrence (HR 2.25, p < .001). The main prognostic determinant for each target outcome was Child-Pugh score.

CONCLUSIONS

Our study confirms that curative treatments should always be preferred when applicable in early-stage HCC, but that in cases where this is not possible, TACE is a reasonable albeit inferior treatment option. In addition, it provides unique prognostic information on a significant proportion of patients with early-stage disease in whom curative therapy is not applicable.

[Stereotactic body radiation therapy for hepatocellular carcinoma: Results from a retrospective multicentre study]

PURPOSE

The purpose of this paper was to describe local control, overall survival, progression-free survival and toxicity of CyberKnife^®-based stereotactic body radiation therapy of hepatocellular carcinoma.

MATERIAL AND METHODS

Records of all the patients treated for hepatocellular carcinoma at the Eugene-Marquis cancer centre, Rennes and the Bretonneau hospital, Tours (France), between November 2010 and December 2016, were reviewed. Radiation therapy was performed as a salvage treatment, while awaiting liver transplantation or if no other treatment was possible.

RESULTS

One hundred and thirty-six patients were consecutively included in the study. The median follow-up was 13months. Median total dose prescribed, fractionation and overall treatment time were respectively 45Gy, three fractions and 5 days. Overall survival, progression-free survival and local control rates at 1year and 2years were 79.8 % and 63.5 %, 61.3 % and 39.4 %; 94.5 % and 91 %. Two grade 3 acute toxicity events and two grade 4 late toxicity events corresponding to a duodenal ulcer have been reported. Seven patients underwent classic radiation-induced hepatitis and 13 patients showed non-classical radiation-induced hepatitis. Barcelona Clinic Liver Cancer stage, World Health Organisation grade and planning target volume were correlated with overall survival in univariate Cox analysis.

CONCLUSION

Stereotactic body radiation therapy is effective and well-tolerated for inoperable hepatocellular carcinoma or as a bridge to liver transplantation. Toxicity is mainly related to cirrhotic background and requires a selection of patients and strict dose constraints.

Comparison of Combined Therapy Using Conventional Chemoembolization and Radiofrequency Ablation Versus Conventional Chemoembolization for Ultrasound-Invisible Early-Stage Hepatocellular Carcinoma (Barcelona Clinic Liver Cancer Stage 0 or A)

Objective

To compare the therapeutic efficacy between conventional transarterial chemoembolization (cTACE) and combined therapy using cTACE and radiofrequency ablation (RFA) in ultrasound (US)-invisible early stage hepatocellular carcinoma (HCC).

Materials and Methods

From January 2008 to June 2016, 167 patients with US-invisible early stage HCCs were treated with cTACE alone (cTACE group; n = 85) or cTACE followed by immediate fluoroscopy-guided RFA targeting intratumoral iodized oil retention (combined group; n = 82). Procedure-related complications, local tumor progression (LTP), time to progression (TTP), and overall survival (OS) were compared between the two groups. Multivariate analyses were performed to identify prognostic factors.

Results

There was no major complication in either group. The cTACE group showed higher 1-, 3-, and 5-year LTP rates than the combined group; i.e., 12.5%, 31.7%, and 37.0%, respectively, in the cTACE group; compared to 7.3%, 16.5%, and 16.5%, respectively, in the combined group; p = 0.013. The median TTP was 18 months in the cTACE group and 24 months in the combined group (p = 0.037). Cumulative 1-, 3-, and 5-year OS rates were 100%, 93.2%, and 87.7%, respectively, in the cTACE group and 100%, 96.6%, and 87.4%, respectively, in the combined group (p = 0.686). Tumor diameter > 20 mm and cTACE monotherapy were independent risk factors for LTP and TTP.

Conclusion

Combined therapy using cTACE followed by fluoroscopy-guided RFA is a safe and effective treatment in US-invisible early stage HCCs. It provides less LTP and longer TTP than cTACE alone.

Transarterial chemoembolization as a substitute to radiofrequency ablation for treating Barcelona Clinic Liver Cancer stage 0/A hepatocellular carcinoma

Background and Aim

Transarterial chemoembolization (TACE) is the standard procedure for treating Barcelona clinic liver cancer (BCLC) stage B hepatocellular carcinoma (HCC). However, it is often carried out in the treatment of BCLC stage 0/A HCC for various reasons. This study aimed to elucidate the prognosis for BCLC stage 0/A HCC patients treated with TACE or with radiofrequency ablation (RFA).

Materials and Methods

The prognosis of 242 BCLC stage 0/A HCC patients within Milan criteria who underwent initially TACE or RFA were retrospectively analyzed using propensity score matching analysis.

Results

The analyses of baseline patient characteristics revealed that the maximum tumor size and the proportion of BCLC stage A patients were significantly higher in patients treated with TACE than in those treated with RFA (P<0.001 and 0.047, respectively). After adjusting these factors using propensity score matching (1:3 matching), patients treated with TACE (n=32) and those treated with RFA (n=96) were further analyzed. The local recurrence rate was significantly higher in the TACE group than in the RFA group (P<0.001). However, the overall survival (OS) in HCC patients treated with TACE was comparable to that in HCC patients treated with RFA (1 year, 93.5 vs. 95.8%; 3 years, 75.4 vs. 85.8%; 5 years, 61.8 vs. 70.7%; P=0.196). Multivariate analyses followed by univariate analyses revealed that serum bilirubin level (P=0.032), serum albumin level (P=0.008), HBV-DNA (P=0.013), and tumor number (P=0.021) were independent predictors of OS.

Conclusion

TACE can substitute RFA at least in some patients with BCLC 0/A HCC.

Transarterial chemoembolization (TACE) in the management of hepatocellular carcinoma: Results of a French national survey on current practices

PURPOSE

To report current practices of transarterial chemoembolization (TACE) by interventional radiologists (IR) for hepatocellular carcinoma (HCC) through a French national survey.

MATERIALS AND METHODS

An electronic survey was sent by e-mail to 232 IRs performing TACE in 32 private or public centers. The survey included 66 items including indications for TACE, technical aspects of TACE, other locally available treatments for HCC, follow-up imaging and general aspects of interventional radiology practices.

RESULTS

A total of 64 IRs (64/232; 27%) answered the survey. Each IR performed a mean of 49±45 (SD) TACE procedures per year. Marked variations in indications for TACE in HCC were observed. Six percent of IRs (4/64) treated only patients with Barcelona Clinic Liver Cancer (BCLC) stage B HCC. Antibioprophylaxis was not used by 43/64 of IRs (67%). The number of HCC nodules was considered to select conventional TACE versus drug-eluting beadsTACE (DEB-TACE) by 17/49 IRs (35%) followed by patient performance status and Child-Pugh score by 6/49 IRs (12%). Seventy-three percent of IRs (45/62) treated nodules selectively in patients with unilobar disease with cTACE. Thirty-three percent of IRs (21/64) planned systematically a second TACE session. Doxorubicin was the most frequently used drug (52/64; 81%) and 15/64 IRs (23%) used gelatine sponge as the only embolic agent. For DEB-TACE, 100-300μm beads were used by 26/49 IRs (53%) and no additional embolization was performed by 19/48 IRs (39%). Monopolar radiofrequency technique was widely available (59/63; 94%) compared to selective internal radiation therapy (37/64; 58%). Magnetic resonance imaging was used for follow-up by 13/63 IRs (20%).

CONCLUSION

Current practices of TACE for HCC varied widely among IRs suggesting a need for more standardized practices.

Feasibility and Efficacy of Microwave Ablation Combined with Iodine-125 Seed Implantation in Local Control of Recurrent Retroperitoneal Liposarcomas: Initial Clinical Experience

Surgical resection is the primary treatment option for retroperitoneal liposarcomas, but complete resection is difficult and postoperative recurrence and metastasis are common. This prospective study analyzed the feasibility and efficacy of microwave ablation combined with iodine‐125 seed implantation in the local control of recurrent retroperitoneal liposarcomas.

Introduction.

The objective of the present study was to evaluate the feasibility, safety, and short‐term efficacy of microwave ablation (MWA) combined with iodine‐125 (¹²⁵I) seed implantation in recurrent retroperitoneal liposarcomas (rRPLs).

Materials and Methods.

From September 2012 to March 2015, 11 patients were enrolled in this prospective study. Eleven tumors (median, 9 cm; range, 5.5–12.5 cm) were treated with computerized tomography‐guided MWA for 11 sessions and ¹²⁵I seed implantation for 18 sessions. ¹²⁵I seed implantation was performed 4 weeks after MWA.

Results.

There were no procedure‐related deaths. Post‐MWA pain (grade ≥2) was the most common complication (6 of 11 patients, 54.5%), and fever (grade ≥2) was observed in two patients. Reversible nerve injury, defined as transient limb paresthesia or leg weakness, was observed in one patient. There were fewer complications associated with the ¹²⁵I seed implantation procedure compared with the MWA procedure. All 11 patients who underwent the MWA procedure achieved a partial response (PR), according to the modified Response Evaluation Criteria in Solid Tumors, 1 month post‐ablation; after ¹²⁵I seed implantation was performed, a complete response was observed in three, five, and six target tumors in 3, 6, and 12 months, respectively.

Conclusion.

In selected patients with rRPLs, MWA combined with ¹²⁵I seed implantation is feasible and safe with favorable local control efficacy.

Implications for Practice.

This study evaluated the feasibility, safety, and short‐term efficacy of microwave ablation (MWA) combined with iodine‐125 (¹²⁵I) seed implantation in recurrent retroperitoneal liposarcomas (rRPLs). Results suggest that a single session of MWA may be not sufficient in large‐volume rRPLs and that as a supplement treatment, ¹²⁵I seed implantation is safe and easy accessible. MWA combined with ¹²⁵I seed has excellent local control effectiveness, and long‐term efficacy and survival benefit still need to be more comprehensively evaluated.

Transarterial chemoembolization prior to liver transplantation for patients with hepatocellular carcinoma: A meta-analysis

BACKGROUND AND AIM

A debate exists over whether using preoperative transarterial chemoembolization for patients with hepatocellular carcinoma before liver transplantation. Numerous studies have been investigating on this, but there is still no unanimous conclusion about the effect of preoperative transarterial chemoembolization. We conducted the meta-analysis of all available studies to systematically evaluate the influence of preoperative transarterial chemoembolization on liver transplant.

METHODS

A systematic search was performed by two authors (Si TF. and Guan RY.) through PubMed, Embase, Cochrane, and Science Citation Index Expanded, combined with Manual Retrieval and Cited Reference Search. The searching cut-off date was 2016/07/31, and all the data obtained were statistically analyzed using Review Manager version 5.1 software (Copenhagen, The Nordic Cochrane Center, The Cochrane Collaboration, 2011) recommended by Cochrane Collaboration.

RESULTS

The study showed that there was no difference between the experimental group and the control group on perioperative mortality (RR = 1.10, 95% confidence interval (CI) = [0.49-2.48], P = 0.82) or biliary complications (RR = 0.96, 95%CI = [0.66-1.39], P = 0.83). Preoperative transarterial chemoembolization had no obvious effect on improving overall survival (HR = 1.05, 95%CI = [0.65-1.72], P = 0. 83) but would result in a higher rate of vascular complications (RR = 2.01, 95%CI = [1.23-3.27], P = 0.005) and a reduction of disease free survival (HR = 1.66, 95%CI = [1.02-2.70], P = 0.04). Subgroup analysis also revealed that patients from transarterial chemoembolization group in Asia had a much lower overall survival rate (HR = 2.65, 95%CI = [1.49-4.71], P = 0.0009) compared with the control group.

CONCLUSIONS

Considering the possible adverse impacts on liver transplantation and the variation in sensitivity to transarterial chemoembolization, clinicians should be more cautious when considering transarterial chemoembolization as the bridging therapy for patients in the waiting list.

Transarterial chemoembolization for early stage hepatocellular carcinoma decrease local tumor control and overall survival compared to radiofrequency ablation

BACKGROUND & AIMS

To compare treatment failure and survival associated with ultrasound-guided radiofrequency ablation (RFA) and trans-arterial chemoembolization (TACE) for early-stage HCC in Child-Pugh A cirrhosis patients.

METHODS

122 cirrhotic patients (RFA: 61; TACE: 61) were well matched according to cirrhosis severity; tumor size and serum alpha-fetoprotein. TACE was performed in case of inconspicuous nodule on US or nodule with "at risk location". Treatment failure was defined as local tumor progression (LTP) and primary treatment failure (failing to obtain complete response after two treatment session). Treatment failure and overall survival (OS) were compared after coarsened exact matching. Cox proportional model to assess independent predictive factors was performed.

RESULTS

No significant difference was seen for baseline characteristics between the two groups. Mean tumor size was 3cm in both group with 41% HCC>3cm. Treatment failure rates after TACE was 42.6% (14 primary treatment failures and 12 LTP) and 9.8% after RFA (no primary treatment failure and 6 LTP) P < 0.001. TACE was the only predictive factor of treatment failure (Hazard ratio: 5.573). The 4-years OS after RFA and TACE were 54.1% and 31.5% (P = 0.042), respectively.

CONCLUSION

For Child-Pugh A patients with early-stage HCC, alternative treatment as supra-selective TACE to RFA regarded as too challenging using common US guidance decrease significantly the local tumor control and overall survival. Efforts to improve feasibility of RFA especially for inconspicuous target have to be made.

Subcentimeter hypervascular nodules with typical imaging findings of hepatocellular carcinoma on gadoxetic acid-enhanced MRI: Outcomes of early treatment and watchful waiting

OBJECTIVES

To compare treatment outcomes of subcentimeter hypervascular nodules at high risk for developing into hepatocellular carcinomas (SHNHR) between early treatment and watchful waiting until progression to overt hepatocellular carcinoma (HCC) groups.

METHODS

SHNHRs were defined as subcentimeter hypervascular nodules with the usual imaging features of HCC on gadoxetic acid-enhanced magnetic resonance imaging (MRI). Among 63 patients with 74 SHNHRs, 27 (37 SHNHRs) received early treatment (treatment of < 1 cm nodules), and 36 (37 SHNHRs) underwent watchful waiting until progression to overt HCC. Risk factor analysis was performed for recurrence-free and local recurrence-free survival.

RESULTS

Among the 36 patients who adopted watchful waiting, 33 eventually underwent treatment because their SHNHRs progressed to overt HCC. For recurrence-free survival, significant risk factors included number of previous treatments (HR, 1.181; p < 0.001), tumour number (HR, 1.943; p = 0.009), and α-feto protein level (HR, 1.005; p = 0.037) in the multivariate analyses. Treatment strategy was not a significant risk factor for recurrence-free survival. For local recurrence-free survival from the date of treatment, only treatment modality (transarterial chemoembolization) (HR, 6.879; p = 0.002) was a significant risk factor.

CONCLUSION

Recurrence-free survival was not significantly different between early treatment and watchful waiting for SHNHRs.

KEY POINTS

• Recurrence-free survival did not vary between the two treatment strategies. • Treatment modality was a significant factor for local recurrence-free survival. • Number of treatments, tumour number, and α-FP were risk factors for recurrence.

Cone Beam CT-Guided Chemoembolization of Probable Hepatocellular Carcinomas Smaller than 1 cm in Patients at High Risk of Hepatocellular Carcinoma

PURPOSE

To evaluate the effectiveness and safety of cone-beam computed tomography (CT)-guided chemoembolization for probable hepatocellular carcinomas (HCCs) smaller than 1 cm in patients at high risk for HCC.

MATERIALS AND METHODS

From December 2009 to May 2014, 57 patients (43 male and 14 female; mean age, 61.1 y) at high risk for HCC underwent cone-beam CT-guided conventional chemoembolization for 79 treatment-naive probable HCCs < 1 cm. Probable HCCs were diagnosed when hepatic nodules showed arterial enhancement and washout on dynamic CT or magnetic resonance images. The Kaplan-Meier method and Cox proportional-hazards regression were used to evaluate the time to local progression (TTLP), time to progression (TTP), and overall survival (OS).

RESULTS

Initial follow-up images obtained 2-3 months after chemoembolization showed complete response in all 79 tumors. The 1-, 2-, and 3-year local progression rates were 10.4%, 21.7%, and 35.7%, respectively. Subsegmental catheterization (P < .001; hazard ratio [HR] = .041) and segmental catheterization (P = .001; HR = .049) were significantly associated with longer TTLP. The 1-, 2-, and 3-year progression rates were 40.5%, 66.7%, and 78.6%, respectively. Tumor multiplicity (P = .004; HR = 2.612) was a significant risk factor for shorter TTP. The 1-, 2-, and 3-year OS rates were 100%, 98.2%, and 88.5%, respectively. Child-Turcotte-Pugh class B disease (P = .029; HR = 5.989) was significantly associated with shorter OS. No complications occurred after chemoembolization.

CONCLUSIONS

Cone-beam CT-guided chemoembolization can be a useful and safe option for probable HCCs < 1 cm in patients at high risk for HCC.

Embolization for Bleeding after Hepatic Radiofrequency Ablation

PURPOSE

To evaluate safety and clinical efficacy of embolization for management of bleeding after hepatic radiofrequency (RF) ablation.

MATERIALS AND METHODS

From January 2000 to December 2014, 5,196 patients with 9,743 tumors underwent 8,303 RF ablation sessions. Of these patients, 62 experienced bleeding after hepatic RF ablation; 15 patients (12 men and 3 women; mean age 62 y; range, 49-76 y) underwent embolization and composed the final study cohort. Tumors were hepatocellular carcinomas in 13 (87%) patients and metastatic adenocarcinomas from colorectal cancer in 2 (13%) patients. Mean number of tumors was 1.5 (22 nodules; range, 1-3). Tumor locations were segment I (n = 1), segment II (n = 2), segment III (n = 1), segment IV (n = 1), segment V (n = 3), segment VI (n = 5), segment VII (n = 1), and segment VIII (n = 9). Mean tumor size was 2.3 cm (range, 0.9-5 cm).

RESULTS

Median time interval between presentation and angiography was 22 hours (mean 38.4 h; range, 3-168 h). On angiography, contrast extravasation with or without pseudoaneurysm was seen in all 15 patients; 14 patients underwent transarterial embolization, and 1 patient underwent percutaneous transhepatic portal vein embolization. Successful hemostasis was achieved in all patients. There was no rebleeding within 30 days after embolization. No embolization-related major complications were observed.

CONCLUSIONS

Embolization is safe and effective for controlling bleeding related to hepatic RF ablation without the need for surgery.

Radiofrequency hyperthermia-enhanced herpes simplex virus-thymidine kinase/ganciclovir direct intratumoral gene therapy of hepatocellular carcinoma

PURPOSE

To determine the feasibility of using radiofrequency hyperthermia (RFH) and to enhance the therapeutic effect of herpes simplex virus-thymidine kinase/ganciclovir (HSV-TK/GCV) for the treatment of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Human HCC cells (HepG2) were first transfected with lentivirus/luciferase. For both in vitro confirmation and in vivo validation, luciferase-labeled HCC cells and HCC tumour xenografts on mice received different treatments: (i) combination therapy of intratumoral HSV-TK/GCV-mediated gene therapy plus magnetic resonance imaging heating guidewire (MRIHG)-mediated RFH; (ii) gene therapy only; (iii) RFH only; and (iv) phosphate-buffered saline (PBS) as control. Cell proliferation was quantified. Tumour changes were monitored by ultrasound imaging and bioluminescence optical imaging before and at days 7 and 14 after treatments, which were correlated with subsequent histology.

RESULTS

In vitro, the lowest cell proliferation was seen in the combination therapy group compared with control groups (29 ± 6% vs. 56 ± 9%, 93 ± 4%, and 100 ± 5%, p < .05). Ultrasound imaging of treated animal xenografts showed smaller relative tumour volume in combination therapy group than those in three control groups (0.74 ± 0.19 vs. 1.79 ± 0.24, 3.14 ± 0.49 and 3.22 ± 0.52, p < .05). Optical imaging demonstrated significant decrease of bioluminescence signals of tumours in the combination therapy group, compared to those in three control groups (1.2 ± 0.1 vs. 1.9 ± 0.2% vs. 3.3 ± 0.6% vs. 3.5 ± 0.4%, p < .05). These imaging findings were correlated well with histologic confirmation.

CONCLUSION

RFH can enhance HSV-TK/GCV-mediated gene therapy of HepG2 cell line and mice human HCC xenografts, which may open new avenues for effective management of HCC using MR/RFH integrated interventional gene therapy.

Transarterial Chemoembolization versus Radiofrequency Ablation for Recurrent Hepatocellular Carcinoma after Resection within Barcelona Clinic Liver Cancer Stage 0/A: A Retrospective Comparative Study

PURPOSE

To compare outcomes of transarterial chemoembolization with radiofrequency (RF) ablation in treatment of recurrent hepatocellular carcinoma (HCC) after resection within Barcelona Clinic Liver Cancer (BCLC) stage 0/A.

MATERIALS AND METHODS

From January 2007 to December 2011, 110 consecutive patients with recurrent HCC meeting BCLC stage 0/A criteria underwent transarterial chemoembolization (n = 78; mean tumor size, 1.9 cm ± 1.0) or RF ablation (n = 32; mean tumor size, 1.9 cm ± 0.6) as initial treatment. The primary outcome was overall survival (OS). Kaplan-Meier method was used to construct survival curves, which were compared by log-rank test. Prognostic factors for OS were analyzed using univariate and multivariate Cox proportional hazard models.

RESULTS

No significant differences between baseline clinical characteristics of the 2 treatment groups were identified. The 1-, 3-, and 5-year OS rates were 89.7%, 61.0%, and 36.6% for the transarterial chemoembolization group and 90.1%, 72.8%, and 60.0% for the RF ablation group. There was no significant difference in OS rates between the groups (P = .159). Subgroup analysis indicated that RF ablation achieved better survival than transarterial chemoembolization among patients ≤ 55 years old and patients with BCLC stage 0 (P = .036 and P = .045). Multivariate analysis revealed that serum albumin (≤ 35 g/L) (hazard ratio = 2.797; 95% confidence interval, 1.366-2.726; P = .005) and α-fetoprotein (> 400 ng/mL) (HR = 2.336; 95% CI, 1.210-4.508; P = .011) levels before treatment were 2 significant risk factors for poor prognosis.

CONCLUSIONS

Transarterial chemoembolization might provide a similar OS as RF ablation in patients with recurrent BCLC stage A HCC. However, RF ablation could provide better OS in patients with recurrent BCLC stage 0 HCC.

Surgical Resection Versus Radiofrequency Ablation for Single Hepatocellular Carcinoma ≤ 2 cm in a Propensity Score Model

OBJECTIVES

To evaluate the efficacy of surgical resection (SR) and radiofrequency ablation (RFA) for single hepatocellular carcinoma (HCC) 2  cm or less.

BACKGROUND

The optimal management for Barcelona Clínic Liver Cancer (BCLC) very early-stage HCC is undetermined.

METHODS

Between 2002 and 2013, a total of 237 (SR, 109; RFA, 128) patients with BCLC very early-stage HCC were enrolled. Their overall survival (OS) and recurrence-free survival (RFS) were compared. Propensity score matching analysis identified 79 matched pairs of patients to compare outcomes.

RESULTS

At baseline, patients with SR were younger and had larger tumors (both P < 0.05). The 5-year OS rates were 81% versus 76% (P = 0.136), whereas 5-year RFS rates were 49% versus 24% (P < 0.001) for SR and RFA groups, respectively. In the propensity model, the baseline variables were well balanced between 2 groups. Surgical resection was significantly associated with better OS and RFS compared with RFA; the 5-year OS rates were 80% versus 66% (P = 0.034), and 5-year RFS rates were 48% versus 18% (P < 0.001) for SR and RFA groups, respectively. The Cox proportional hazards model identified RFA as an independent predictor for mortality and tumor recurrence in the propensity model (hazard ratio, 2.120 and 2.421, respectively; both P < 0.05). Patients with recurrent HCC had inferior prognosis compared with patients without recurrence (P = 0.001). However, the survival after recurrence was similar between patients initially treated with SR or RFA (P = 0.415).

CONCLUSIONS

Surgical resection provides better long-term OS and RFS compared with RFA in patients with BCLC very early-stage HCC. Surgical resection should be considered as the first-line treatment for these patients.

Comparison of transarterial chemoembolization with radiofrequency ablation for unresectable Barcelona Clinic Liver Cancer stage 0/A hepatocellular carcinoma: a propensity score matching

BACKGROUND AND AIM

Radiofrequency ablation (RFA) is recommended as one of the standard treatments for early hepatocellular carcinoma (HCC). Because of high-risk tumor locations unfit for RFA, transarterial chemoembolization (TACE) is served as an alternative option in these settings. To define the role of TACE on early HCC, we retrospectively compared the efficacies of TACE with RFA in patients with unresectable Barcelona Clinic Liver Cancer (BCLC) stage 0/A HCC.

MATERIALS AND METHODS

Treatment-naïve patients with unresectable BCLC stage 0/A HCC who underwent TACE or RFA were recruited from 2007 to 2011. In all, 208 patients who underwent TACE and 235 patients who underwent RFA were included in the final analysis. Using the propensity model to correct selection bias, 103 patients were selected from each treatment arm. Cumulative overall survival (OS) as the primary end point was compared after adjustment with propensity score matching.

RESULTS

In all patients, the OS rate was significantly higher in patients treated with RFA than that in those who received TACE (1-, 3-, and 5-year OS rates, 93.7%, 72.6%, and 58.1% vs 88.1%, 50.3%, and 30.4%, respectively; P < 0.001). However, adjustment with propensity score matching yielded comparable OS between the two groups (P = 0.207). Subgroup analysis showed that RFA provided better OS than TACE in patients with serum γ-glutamyltranspeptidase < 75 IU/L (P = 0.035). Univariate and subsequent multivariate analyses revealed that Child-Pugh class B (hazard ratio = 1.805; 95% confidence interval, 1.805-3.003; P = 0.023) and hepatitis C virus positivity (hazard ratio = 2.478; 95% confidence interval, 1.136-5.404; P = 0.023) were independent predictors of poor prognosis.

CONCLUSION

Transarterial chemoembolization is an effective alternative treatment for unresectable BCLC stage 0/A HCC when RFA is not feasible.

Treatment of hepatocellular carcinoma with portal venous tumor thrombosis: A comprehensive review

The natural history of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is dismal (approximately 2-4 mo), and PVTT is reportedly found in 10%-40% of HCC patients at diagnosis. According to the Barcelona Clinic Liver Cancer (BCLC) Staging System (which is the most widely adopted HCC management guideline), sorafenib is the standard of care for advanced HCC (i.e., BCLC stage C) and the presence of PVTT is included in this category. However, sorafenib treatment only marginally prolongs patient survival and, notably, its therapeutic efficacy is reduced in patients with PVTT. In this context, there have been diverse efforts to develop alternatives to current standard systemic chemotherapies or combination treatment options. To date, many studies on transarterial chemoembolization, 3-dimensional conformal radiotherapy, hepatic arterial chemotherapy, and transarterial radioembolization report better overall survival than sorafenib therapy alone, but their outcomes need to be verified in future prospective, randomized controlled studies in order to be incorporated into current treatment guidelines. Additionally, combination strategies have been applied to treat HCC patients with PVTT, with the hope that the possible synergistic actions among different treatment modalities would provide promising results. This narrative review describes the current status of the management options for HCC with PVTT, with a focus on overall survival.